shortness of breath/ chest pain

[PCP]

Okay, going out on a limb here folks as I am new to the forum and still fairly new to the world of EMS. If you are treating a patient that is having SOB with the Ventolin protocol and while giving them the first dose of Ventoline they develop chest pain. What would one do? Now the pt. states they do have Asthma, but also have suffered two episodes of Angina within the last two years and are prescribed NItro.

Should one stop the treatment of Ventolin, apply high flow O2 and then start down the Chest Pain protocol or do you continue with the SOB protocol while questioning the the pt. about the chest pain they suddenly developed?

I guess my thinking is yes, they have a cardiac hx, but at the same time they have Asthma and said they have been exposed to lets say dust which brings on their Asthma and are having a hard time breathing and used their puffer that did not help. I feel I should continue with the Ventolin protocol and question my patient about the chest pain they are experiencing.

Any comments good or bad are welcome!

Sorry if my questions seems a little confusing. If you need any more clarification feel free to ask me.

[rock_shoes]

Breath sounds were? The description of this patient's chest pain was? Other past medical history? Depending on your location I would definitely be calling for ALS intercept as this is not a BLS patient presentation. What precipitated the patient's shortness of breath? You're right to be considering the B1 effects of the ventolin but failing to treat a patient's bronchospasm will harm them more than those effects in the long run. Airway, Breathing, Circulation in this instance. Realistically you can work on both. A nebulizer running at 8LPM of O2 is supplying a significant amount of oxygen already and allowing you to treat the bronchospasm. I've never viewed running a nebulizer as a contraindication for nitro.

Remember we're working under treatment guidlines now. If it's in your scope of practice, and you have good justification for your actions, do it. As a bit of a side note I would be placing at least an 18g IV prior to the nitro. It isn't protocol but without a monitor for PCP's it damn well should be.

[PCP]

Breath sounds were? The description of this patient's chest pain was? Other past medical history? Depending on your location I would definitely be calling for ALS intercept as this is not a BLS patient presentation. What precipitated the patient's shortness of breath? You're right to be considering the B1 effects of the ventolin but failing to treat a patient's bronchospasm will harm them more than those effects in the long run. Airway, Breathing, Circulation in this instance. Realistically you can work on both. A nebulizer running at 8LPM of O2 is supplying a significant amount of oxygen already and allowing you to treat the bronchospasm. I've never viewed running a nebulizer as a contraindication for nitro.

Remember we're working under treatment guidlines now. If it's in your scope of practice, and you have good justification for your actions, do it. As a bit of a side note I would be placing at least an 18g IV prior to the nitro. It isn't protocol but without a monitor for PCP's it damn well should be.

The breath sounds are audible wheezes bilateral to the bases. The patient describes the chest pain as "Crushing", The pt just tells you that he had an MI two years ago and has been prescribed Nitro, but has never had to use it before. The patient tells you that his Asthma is brought on by dust and that he had been cleaning out his basement when he started to find it hard to breathe.

The town I am working in does not have ALS, so it is up to us PCPs to deal with this kind of situation. That is my thinking as well, is that the B1 effects from the Ventolin could be causing him to have chest pain, but on the other hand the chest pain could be causing his SOB.

So, you state that you have never viewed running a nebulizer as a contraindication for nitro. I did not think of that, so what you are saying is that I could continue running the Ventolin protocol, as well as treat the chest pain with Nitro?

Sorry people I should have posted this question in the forum for scenarios

[rock_shoes]

The breath sounds are audible wheezes bilateral to the bases. The patient describes the chest pain as "Crushing", The pt just tells you that he had an MI two years ago and has been prescribed Nitro, but has never had to use it before. The patient tells you that his Asthma is brought on by dust and that he had been cleaning out his basement when he started to find it hard to breathe.

In that case definitely continue with the Ventolin. High flow O2 won’t do this fellow any good if his lungs are so seized up gas exchange can’t occur.

The town I am working in does not have ALS, so it is up to us PCPs to deal with this kind of situation. That is my thinking as well, is that the B1 effects from the Ventolin could be causing him to have chest pain, but on the other hand the chest pain could be causing his SOB.

Cardiac asthma is a possibility. The chest pain still won’t get any better if he can’t breathe. It’s kind of a “6 in 1 half dozen of the other” situation. Medical direction probably wouldn’t fault you for heading down the cardiac chest pain route and dropping the Ventolin but they would be pleased to see you putting on your thinking cap and treating both in this situation.

So, you state that you have never viewed running a nebulizer as a contraindication for nitro. I did not think of that, so what you are saying is that I could continue running the Ventolin protocol, as well as treat the chest pain with Nitro?

I would as long as his blood pressure was in an acceptable range. This is essentially virgin nitro with this patient so having IV access in place prior to giving nitro is all the more important. Then its GLH to the big H because this patient is really beyond the PCP SOP for any kind of continuing care.

[PCP]

I agree this is a complex case and is a little out of my league, but this case was presented to me while taking my program a few years back and I have never forgotten this scenario as I found it very complex and felt there was some things going on with the pt. that I did not understand.

Thanks for you input and yes this guy would be flowen out or we would be transporting him to Nanaimo with a nurse on board.

[chbare]

Please quantify and qualify this concept of "high flow O2?"

Take care,

chbare.

[HERBIE1]

What was the patient's S&S's that caused the asthma treatment? History of present illness? Sudden or gradual onset of the SOB? Degree of distress? Lung sounds, pulse ox, etc? Is a 12 lead EKG available? If I had to guess, I would say that it sounds like the SOB is secondary to angina or an MI. Is the chest pain pleuritic- ie is the patient complaining of pneumonia type symptoms, and opening the airways is causing him to be able to breathe more deeply, causing the pain?

Ventolin can increase oxygen demand by increasing the heart rate, which would explain the chest pain after the treatment had started. Personally I would be aggressively treating the chest pain, which- barring asthma symptoms- would hopefully alleviate the chest pain and the SOB. Unless the person was actively wheezing or tight, I wouldn't be as worried about the ventolin.

I would throw this to medical control, outline everything and ask which protocol they wanted you to pursue.

Lots of questions.

[Just Plain Ruff]

Please quantify and qualify this concept of "high flow O2?"

Take care,

chbare.

High flow Oxygen is any flow rate where you can hear the oxygen flow from the tubing.

Or if they are in a nursing home high flow is 3lpm via non-rebreather mask.

[Richard B the EMT]

It has been mentioned the patient has a history of a previous MI, and has Nitro pills available. Has the patient taken a Nitro? How long ago? Was it effective? What was the patient doing at onset of the chestpain? Has anything the patient done been effective in eliminating/reducing the chestpain?

[PCP]

It has been mentioned the patient has a history of a previous MI, and has Nitro pills available. Has the patient taken a Nitro? How long ago? Was it effective? What was the patient doing at onset of the chestpain? Has anything the patient done been effective in eliminating/reducing the chestpain?

Okay, I see I have opened a can of worms

No the patient has not taken any nitro, as the chest pain came on suddenly while you where treating him for his SOB. The patient is sitting in a chair by the kitchen table. I am just curious to know what is the best plan of action with a patient who is experiencing SOB and has a hx of Asthma and was exposed to dust and that is what triggers his Asthma. While treating this patient he suddenly develops chest pain. I am curious to know, do you discontinue with the Ventolin protocol give high flow O2 10-15 LPM and start down the chest pain protocol road.

As well as where I am station we do not have ALS or can we atach a 3 or a 12 lead to this guy and monitor his rythm.

So what is the best plan of action for a PCP at the PCP level without ALS available

What was the patient's S&S's that caused the asthma treatment? History of present illness? Sudden or gradual onset of the SOB? Degree of distress? Lung sounds, pulse ox, etc? Is a 12 lead EKG available? If I had to guess, I would say that it sounds like the SOB is secondary to angina or an MI. Is the chest pain pleuritic- ie is the patient complaining of pneumonia type symptoms, and opening the airways is causing him to be able to breathe more deeply, causing the pain?

Ventolin can increase oxygen demand by increasing the heart rate, which would explain the chest pain after the treatment had started. Personally I would be aggressively treating the chest pain, which- barring asthma symptoms- would hopefully alleviate the chest pain and the SOB. Unless the person was actively wheezing or tight, I wouldn't be as worried about the ventolin.

I would throw this to medical control, outline everything and ask which protocol they wanted you to pursue.

Lots of questions.

The pt. was cleaning out his basement and was exposed to dust which brings on his Asthma. Has been diagnosed with Asthma for over 10 years. His SOB was sudden When you walked in the pt is sitting in a tripod position, Lung sounds-Bilateral Wheezes to the bases, Initial pulse OX reading was 93 percent.

There is no 12 lead EKG available (small town) No Pleuritic chest pain

I dont have a medical control that I can call, it is left up to us and we need to decide the best plan of action